Quality of life of dermatology outpatients and its associated factors in Halibet National Referral Hospital in Asmara, Eritrea

Skin diseases are prevalent globally and can have detrimental effects on the individual’s health-related quality of life (HRQoL). The treatment of dermatological patients typically focuses on clinical signs and symptoms and a subjective view of the impact of the disease on the patient’s life. Assessing quality of life can help provide patients with better service, by acknowledging their real needs and interfering with treatment decisions. The aim of the study was therefore to assess quality of life of dermatology outpatients and its associated factors. An analytical cross-sectional study was conducted in the dermatology clinic of Halibet National Referral Hospital in Asmara, Eritrea. HRQoL data were collected between May 6 and August 18, 2022 using a validated standard tool (Skindex-29). Descriptive statistics, logistic regression and paired t-test were employed using Statistical Package for Social Sciences (Version-26.0). A total of 375 dermatology clinic out-patients with a median age of 29 (Interquartile range: 25) were included in the study. The most commonly seen skin diseases were eczema, seborrhoeic dermatitis and tinea pedis. Emotion, symptom, and functioning domains of HRQoL were severely impaired in 75.7%, 50.4% and 57.6% of all dermatology outpatients, respectively. More than half of the respondents (57.9%) had a severely impaired overall HRQoL. In the overall HRQoL, being a rural resident [Adjusted Odds Ratio (AOR) 1.98, 95% CI 1.18, 3.33] and presence of chronic illness (AOR 2.16, 95% CI 1.22, 3.82) were significantly associated with severely impaired overall quality of life. A significantly higher mean score (p < 0.001) was observed in emotion [Mean (M) = 55.60, Standard Deviation (SD) = 21.0] as compared to functioning (M = 46.89, SD = 21.2). On the other hand, significantly higher mean score (p < 0.001) was observed on symptom (M = 54.08, SD = 20.5) as compared to functioning (M = 46.89, SD = 21.2). Skin diseases severely affected the emotion, functioning, and symptom domains of health-related quality of life. This highlights the importance of providing physical and psychosocial support to patients with dermatologic problems.


Study design and setting
An analytical cross-sectional study with a quantitative approach was conducted in the dermatology clinic of Halibet National Referral Hospital in Asmara, Eritrea.It is the only national referral hospital with a well-established dermatology department providing services to patients with various skin diseases.In Eritrea, healthcare services are highly accessible and affordable, provided at heavily subsidized or nominal costs through the public health system.The healthcare delivery model is structured on a three-tier basis: the primary level consists of health stations, health centers, and community hospitals, serving as the initial point of contact for patients.The secondary level comprises regional referral hospitals and second-contact hospitals within sub-regions, to which patients are referred from the primary level.The tertiary level is made up of national referral hospitals located in the capital city, Asmara.Patients can be referred to higher-level facilities by their healthcare providers, or they can be self-referred directly to secondary or tertiary hospitals if they deem it necessary.This allows for a streamlined and accessible healthcare system that caters to the diverse medical needs of the population.Data were collected from May 6 to August 18, 2022 for a period of 90 working days.

Source and study population
All outpatients attending the dermatology clinic during the study period were the source population.Patients aged 18 years and above who were diagnosed with any skin diseases and willing to participate formed the study population.

Sample size and sampling technique
The sample size was computed by considering the finite population correction factor formula: n = NZ 2 pq/ [pqZ 2 + (N−1)d 2 ].The total sample size (n) was calculated using the following assumptions: expected proportion of patients whose QoL was severely affected by skin disease (p) and those whose QoL is not severely affected by skin disease (q) were taken as 0.5, Z statistic for 95% level of confidence (Z = 1.96), estimated population size (N)

Variable measurement and interpretation
Quality of life was measured with Skindex-29 using 5-point Likert scale ranging from 'never' to 'all the time' .As per the scale guideline, a score of '0' , '25' , '50' , '75' and '100' was given to the responses 'never' , 'rarely' , 'sometimes' , 'often' and 'all the time' , respectively.A scale score was computed by dividing the mean of a patient's responses by the items in a given scale.On the other hand, as per the scale guideline, missing of more than 25% of responses to an item, missing of more than 25% of the items in a domain, and an item with multiple answers (considered as missing item) were not present in this study.Higher score within domains illustrated a higher impact of the skin disease on the patients' quality of life.
According to a literature, the Skindex-29 cut-off scores for severely impaired HRQoL were recognized and showed to have the highest accuracy 3 .As such, the cut-off scores for severely impaired HRQoL of ≥ 52 points on symptoms, ≥ 39 on emotions, ≥ 37 on functioning, and ≥ 44 on the total score were used in this analysis.

Quality assurance
The data collection tool (along with Tigrigna Version of Skindex-29) was peer-reviewed by a panel of experts in the fields of medicine, pharmacy, pharmaco-epidemiology, public health, and epidemiology to verify face and content validity.The data collection tool was then modified as per the comments given by the experts and subject to a pre-test.The pre-test was conducted on 38 participants from 13 to 16 April, 2022 in the dermatology outpatient clinic of Halibet National Referral Hospital.It aided in assessing translation accuracy, estimation of time needed to complete the questionnaire, and familiarizing data collectors.A two-day training workshop was provided for data collectors to clearly understand the study objectives, questionnaires, and approach of conducting the face-to-face interview.To ensure reliability, two pharmacists, NB and TT, who had prior similar experience were selected and oriented to conduct the data collection so as to understand the within and between inter-rater uniformity.

Statistical analysis
The collected data were entered using CSPro (version 7.0), cleaned and exported to IBM Statistical Package for Social Sciences (SPSS) [Version 26.0] for statistical analysis.Descriptive analysis was performed using percentages and mean (Standard Deviation (SD)).The scores of the domains of QoL were computed from the respective items and converted to 100%.Furthermore, the scores were categorized into binary as per the guidelines of the Skindex-29 tool.The factors that affect the domains of QoL and total QoL binary responses were assessed primarily using bivariate logistic regression.Factors that were significant at bivariate were retained for multivariable logistic regression and adjusted odds ratios (AORs) were computed consequently as a measure of association.To determine which domain of the QoL is highly affected, paired t-test was employed for comparisons.Tables and figures were used to present the results.The level of significance for all variables was tested at p value less than 0.05.

Socio-demographic and background characteristics
A total of 375 participants with a median age of 29 (IQR: 25) were enrolled in the study.Two-hundred and one participants (53.6%) were males.The majority of the participants were urban inhabitants (77.3%), aged between 18 and 40 years (67.2%), and completed their secondary education (49.6%).Moreover, 56% of the participants were employed, and 81.6% of them had no chronic illness (Table 1).Detailed socio-demographic and background characteristics of the study population are depicted in Table 1.

Quality of life of the dermatologic outpatients using Skindex-29
In the emotion domain, majority of the respondents (n = 260/375, 69.3%) reported that they frequently worried that their skin condition might get worse.Moreover, most of them (61.6%)frequently worried about getting scars from their skin conditions.However, only one in five of the participants (19.5%) reported that they frequently get frustrated by their skin condition (Table 3).The mean (SD) score of the emotion domain was 55.60 (21.0) out of 100.A total of 284 participants had a severely impaired emotion domain (Fig. 1).
Furthermore, in the domain of symptoms, more than half of the respondents (56%) experienced skin itching all the time.Besides, about 44.5% of them reported that their skin condition frequently burns or stings.On the other hand, 72% of the participants reported that water rarely bothered their skin condition during bathing and hand washing.The mean (SD) score of the symptoms domain was 54.08 (20.5) out of 100.One-hundred eightynine of all the participants had severely impaired symptom domain.
In the functioning domain, about 38.7% of the respondents reported that their skin condition made it hard to work or do hobbies and it also affected their social life.Out of 328 participants who started a sexual life, 79.3% reported that their skin condition rarely interfered with their sex life.Moreover, 70.9% of the respondents reported that their skin condition made showing affection difficult.The mean (SD) score of the functioning domain was 46.89 (21.2) out of 100.A total of 216 participants had a severely impaired functionality (Fig. 1).
The overall mean (SD) score of the quality of life was 51.44 (18.9) out of 100.A total of 217 (57.9%) of the study participants had severely impaired QoL (Fig. 1).www.nature.com/scientificreports/Of the commonly seen skin diseases, patients with eczema, lichen planus, seborrhoeic dermatitis, psoriasis, acne vulgaris, and vitiligo had a severely impaired HRQoL outcome (Table 4).However, patients with pityriasis versicolor had no severely impaired HRQoL outcome.
Multivariable logistic regression indicated that dermatology patients with a primary educational level were two times more likely to experience severely impaired symptom than those with a higher education (AOR 2.60, 95% CI 1.12, 6.03).Moreover, rural residents were approximately two times more likely to experience severely impaired symptom than urban residents (AOR 1.71, 95% CI 1.02, 2.86) (Table 6).
Dermatology patients with a primary educational level were approximately three times more likely to experience severely impaired emotions than those with a higher education (AOR 2.94, 95% CI 1.10, 7.86).Patients with chronic illnesses were two times more likely to experience severely impaired emotions than their counterparts (AOR 2.36, 95% CI 1.11, 4.99).
The elderly population was 64% less likely to experience severely impaired functioning than adults (AOR 0.36, 95% CI 0.18, 0.73).Moreover, rural residents were approximately two times more likely to experience severely impaired functioning than urban residents (AOR 1.82, 95% CI 1.08, 3.08).Patients with chronic illnesses were two times more likely to experience severely impaired functioning than their counterparts (AOR 2.21, 95% CI 1.23, 3.98).
In terms of overall health-related quality of life, rural residents were approximately two times more likely to experience severely impaired quality of life than urban residents (AOR 1.98, 95% CI 1. 18 www.nature.com/scientificreports/chronic illnesses were two times more likely to experience severely impaired quality of life than their counterparts (AOR 2.16, 95% CI 1.22, 3.82) (Table 6).A Chi-square test for trend analysis indicated that there was no significant association between the number of skin diseases in an individual patient and the overall quality of life outcome (χ 2 = 2.34, p = 0.126) (Table 7).

Comparison of the domains of quality of life
Paired comparison of the domains of QoL revealed significantly higher mean score (p < 0.001) in emotion (M = 55.60,SD = 21.0) as compared to functioning (M = 46.89,SD = 21.2).On the other hand, significantly higher  2).However, the mean scores of emotion and symptom were not significantly different (MD = 1.51, 95% CI − 0.31, 3.33, p = 0.103) (Fig. 2).

Discussion
Skin diseases compromise the quality of life of dermatology patients.The problems encountered from skin diseases include physical, psychological, and social consequences 21 .In this study, skin diseases severely impaired the health-related quality of life of study participants in terms of symptoms, emotions, and functioning.The majority of the dermatology outpatients experienced negative emotional effects from their skin diseases worrying about the severity, scarring, and worsening of their condition.Moreover, two out of five subjects felt depressed due to their skin condition.Skin diseases often lead to changes in appearance and negative body image which are associated with poor quality of life 16 .When patients face new symptoms or conditions, they react with fear and concern, impacting their well-being and treatment outcomes 17 .Dermatology patients are also more likely to experience psychiatric comorbidities compared to healthy individuals 22 .Our findings emphasize the importance of addressing adverse psychological outcomes associated with skin diseases which was in line with studies conducted in China 8 , South Korea 23 , and the UK 24 .Therefore, providing psychological support to dermatology  patients is crucial due to the increased risk of psychiatric problems associated with skin diseases.This is supported by a UK study where 77% of the respondents would benefit from more psychological support 24 .
For about half of the respondents, skin diseases severely affected their quality of life in terms of symptoms.Most of them experienced constant itching, burning, or stinging.One out of five patients reported that water worsened their skin condition during bathing and hand washing.The symptoms associated with skin diseases can compromise the quality of life of patients thereby leading to subjective distress and emotional problems.In similar studies, physical symptom was found to be associated with greatest impact on their HRQoL 6,22 .In another study, patients with skin presentation of rashes compared to lesions were also found to have a severely impaired quality of life.Moreover, patients with extensive area of skin involvement suffer far greater than patients with skin cancer 25 .
More than half of the dermatologic outpatients experienced severely impaired functioning due to their skin condition.Several patients reported limitations in daily work and social life interaction, hobbies, and/or forced to stay at home.This aligns with findings of another study, that reported the skin conditions negatively affect patients' routine activities and their social interactions and was associated with increased psychiatric morbidity 7 .Acquiring a primary educational level and being a rural resident were significantly associated with severely impaired quality of life within the symptom domain.Moreover, having a primary educational level and presence of systemic chronic illness were significantly associated with severely impaired emotional domain.
Being a rural resident and presence of systemic chronic illness were significantly associated with severely impaired functional domain and quality of life in general which is similar to findings reported from Belgium 26 .In other comparable study, individuals who are unemployed or living in rural areas were significantly affected 4 .Presence of other systemic chronic illness can aggravate the quality of life of patients which urges healthcare professionals and program managers to focus on a holistic approach that includes psychotherapy to improve the overall QoL of patients.
Moreover, dermatologic patients aged 18-40 years were significantly associated with severely impaired functioning likely due to unique challenges they face.The visibility and stigma of skin conditions can have a greater impact on socially and professionally active adults.Moreover, the psychosocial effects, such as poor body image and low self-confidence, could be more detrimental for adults with a well-established sense of identity and social dynamics.Hence, it is important to pay attention to optimal care that targets all aspects of health problems thereby improving their life conditions.As per the findings of the study, patients with atopic dermatitis (eczema), lichen planus, seborrhoeic dermatitis, psoriasis, acne vulgaris, and vitiligo were found to have significantly impaired overall QoL and had shown a profound psychosocial impairment.However, in a similar study conducted in Saudi Arabia, patients with eczematous dermatitis, connective tissue diseases and immunological disorders scored significantly higher in the symptom domain 27 .
The skin is certainly the most visible organ determining appearance and skin diseases have a detrimental effect on physical, emotional and functional domains of quality of life outcome and social interaction.The importance of this research and its findings are probably of specific interest to countries with socio-economic and cultural status similar to that of Eritrea.Program managers and policy makers are recommended to introduce psychosocial support activities in dermatologic clinics and organize continuous awareness-raising program on early treatment and understanding of skin disease.Besides, dermatologists and other healthcare professionals need to consider treating the soul along with the body to minimize impact of skin diseases.

Limitation of the study
Due to the cross-sectional nature of the study, cause-effect relationship could not be established.This study was conducted in dermatology clinic of a tertiary care hospital, and thus, the findings could not be generalizable to other similar patients attending primary and secondary level health facilities.

Conclusion
Skin diseases severely affected the emotional, functional and symptom domains of health-related quality of life of dermatologic patients.Overall, being a rural resident and having a chronic illness were significantly associated with severely impaired quality of life.To improve the quality of life of patients, program managers and health facility managers should consider introducing psychosocial support in dermatology clinics.

Figure 2 .
Figure 2. Comparison of the domains of quality of life.
Ethical approval was obtained from Ministry of Health (MOH) research ethics and protocol review committee (reference number: 03/09/2019).Besides, permission was obtained beforehand from the medical director and head of outpatient department of the dermatology clinics of Halibet national referral hospital where the actual study and the pre-test were conducted.Study participants were informed about the objectives of the study and written informed consent was obtained before enrollment into the study.Information obtained from this study was kept confidential and used only for this study's purpose.This study conforms to the principles outlined in the Declaration of Helsinki (2013).

Table 2 .
Distribution of common skin diseases seen among the study participants (n = 516).

Table 3 .
Percentage distribution of quality of life domains within Skindex-29 (N = 375).*Frequenciesand percent were calculated out of 328 participants as 47 subjects were not sexually active.Items of

Table 5 .
Determinants, at bivariate level, of severely impaired health-related quality of life across the categories of socio-demographic and other background characteristics of outpatients attending dermatology clinic of Halibet National Referral Hospital, Eritrea, 2022.CI confidence interval; COR crude odds ratio; Ref. reference.*p value < 0.05; **p value < 0.01;

Table 6 .
Determinants, at multivariate level, of severely impaired health-related quality of life across the categories of socio-demographic and other background characteristics of outpatients attending dermatology clinic of Halibet National Referral Hospital, Eritrea, 2022.AOR adjusted odds ratio; CI confidence interval; Ref. reference.*p value < 0.05; **p value < 0.01.

Table 7 .
Association between number of skin diseases and health-related quality of life.